Assignment Instructions
A 72-year-old male presents to the primary care office with shortness of breath, leg swelling, and fatigue. He reports that he stopped engaging in his daily walk with friends three weeks ago because of shortness of breath that became worse with activity. He decided to come to the office today because he is now propping up on at least 3 pillows at night to sleep. He tells the NP that he sometimes sleeps better in his recliner chair. PMH includes hypertension, hyperlipidemia and Type 2 diabetes.
Physical Exam:
BP 106/74 mmHg, Heart rate 110 beats per minute (bpm)
HEENT: Unremarkable
Lungs: Fine inspiratory crackles bilateral bases
Cardiac: S1 and S2 regular, rate and rhythm; presence of 3rd heart sound; jugular venous distention. Bilateral pretibial and ankle 2+pitting edema noted
ECG: Sinus rhythm at 110 bpm
Echocardiogram: decreased wall motion of the anterior wall of the heart and an ejection fraction of 25%
Diagnosis: Heart failure, secondary to silent MI
Discussion Questions
Differentiate between systolic and diastolic heart failure.
State whether the patient is in systolic or diastolic heart failure.
Explain the pathophysiology associated with each of the following symptoms: dyspnea on exertion, pitting edema, jugular vein distention, and orthopnea.
Explain the significance of the presence of a 3rd heart sound and ejection fraction of 25%.
Sample Answer
Differentiate between systolic and diastolic heart failure.
Systolic heart failure occurs when the left ventricle of the heart cannot completely contract. This means the heart cannot forcefully pump blood all through the body in an efficient way. This type of heart failure is also referred to as heart failure with reduced ejection fraction (HFrEF) (Ibe, 2023). Some of the symptoms of systolic heart failure are weakness, fatigue, trouble breathing, confusion, frothy cough, weight gain, not eating enough, confusion, stomach and lower leg swelling. On the other hand, diastolic heart failure occurs when the left ventricle of the heart cannot relax between heartbeats as the tissues are stiff. This type of heart failure is also referred to as heart failure with preserved ejection fraction (HFpEF) (Ibe, 2023). The symptoms of diastolic and systolic heart failure are similar and thus, a test should be conducted to determine which type of heart failure is being experienced.
State whether the patient is in systolic or diastolic heart failure.
Based on the history of the patient and physical assessment, the patient is experiencing systolic heart failure. Some of the symptoms that relate to the diagnosis are jugular vein distention, presence of 3rd heart sound, EF of 25%, lower extremity edema, and fine inspiratory crackles bilateral bases. The diagnosis of Myocardial Infarction (MI) is also a symptom of Systolic Heart Failure as it is caused by decreased levels of contraction.
Explain the pathophysiology associated with each of the following symptoms: dyspnea on exertion, pitting edema, jugular vein distention, and orthopnea.
Dyspnea on exertion is associated with shortness of breath during engagement in physical activities. When a person is exercising, the demand for oxygen in the body increases due to the ability of the body to compensate thus increasing heart rate and blood pressure. Pitting edema is usually due to excess build-up of fluids in the body leading to swelling. This is due to the excess accumulation of fluids in the extracellular spaces due to the alteration in the hemodynamics and poor circulation. Jugular Vein Distention (JVD) occurs when the superior vena cava is distended due to additional pressure on the right ventricle due to the failure of the left ventricle to perform harder (Chaudhary et al., 2022). This leads to the right ventricle working hard leading to the bursting of veins due to accumulation of blood. Orthopnea is a feeling of breathlessness associated with breathlessness due to staying in a reclined position. The breathlessness can be relieved by standing or sitting.
Explain the significance of the presence of a 3rd heart sound and ejection fraction of 25%.
The presence of the third heart sound and ejection fraction of 25% is the first indicator that a person is experiencing left heart failure. These symptoms are also related to restrictive diastolic filling, increased rate of mortality, severe heart failure, and severe mitral regurgitation (Shono et al., 2019).
References
Chaudhary, R., Sukhi, A., Simon, M. A., Villanueva, F. S., & Pacella, J. J. (2022). Role of internal jugular venous ultrasound in suspected or confirmed heart failure: a systematic review. Journal of Cardiac Failure, 28(4), 639-649. https://www.sciencedirect.com/science/article/pii/S1071916421003468
Ibe, U. (2023). What’s the Difference Between Systolic and Diastolic Heart Failure? Healthline. https://www.healthline.com/health/heart-failure/systolic-vs-diastolic#diastolic
Shono, A., Mori, S., Yatomi, A., Kamio, T., Sakai, J., Soga, F., ... & Hirata, K. I. (2019). Ultimate Third Heart Sound. Internal Medicine, 58(17), 2535-2538. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6761354/#:~:text=The%20third%20heart%20sound%20is%20the%20initial%20clue%20suggesting%20left,mortality%20(2%2C3).